<%@ page language="java" contentType="text/html; charset=ISO-8859-1" pageEncoding="ISO-8859-1"%>
<%@ taglib prefix="sec" uri="http://www.springframework.org/security/tags" %>
<%@ taglib prefix="c" uri="http://java.sun.com/jsp/jstl/core"%>
<%@ taglib uri="http://java.sun.com/jsp/jstl/core" prefix="c"%>
<%@ taglib prefix="form" uri="http://www.springframework.org/tags/form" %>
<%@ page session="false"%>
<!DOCTYPE html PUBLIC "-//W3C//DTD HTML 4.01 Transitional//EN" "http://www.w3.org/TR/html4/loose.dtd">
<html>
<head>
<meta http-equiv="Content-Type" content="text/html; charset=ISO-8859-1">
<title>Insert title here</title>
<link rel="stylesheet" href="resources/mytheme/css/main.css">
<link rel="stylesheet" type="text/css" href="resources/mytheme/css/jquery-ui.css">
<script type="text/javascript" src="resources/js/jQuery.js"></script>
<script type="text/javascript" src="resources/js/jquery-ui.js"></script>
<script type="text/javascript" src="resources/js/script.js"></script>
<script type="text/javascript" src="resources/js/Request.js"></script>
<script src="https://maps.googleapis.com/maps/api/js"></script>
</head>
<body>
	<div id="headerContainer">
		<div class="centerContainer">
			<ol>
			<sec:authorize ifAllGranted="ROLE_ADMIN">
				<li><a href="AdminUsers">Users</a></li>
				<li><a href="AdminRejectedClaims">Rejected Claims</a></li>
				<li><a href="AdminAcceptedClaims">Accepted Claims</a></li>
				<li><a href="AdminAllClaims">All Claims</a></li>
			</sec:authorize>
			<sec:authorize ifAnyGranted="ROLE_ADMIN, ROLE_ADJUSTER">
				<li><a href="InsuranceAdjuster">Adjust Claims</a></li>
			</sec:authorize>
			</ol>
		</div>
		<!-- /centerContainer -->
	</div>
	<!-- /headerContainer -->
	<div id="secondHeaderContainer">
		<div class="logoContainer">
			<img src="resources/mytheme/images/logo2.png" alt="logo" width="205"
				height="89">
		</div>
		<!-- /logoContainer -->
		<div class="navContainer">
			<ul id="navWrapper">
				<li><a href="/AcmeClaims">Home</a></li>
				<sec:authorize ifNotGranted="ROLE_ADMIN">
				<c:if test="${pageContext.request.userPrincipal.name != null}">
					<li>
						<!-- Menu A --> <a href="#">Claims</a>
						<ul>
							<li><a href="ClaimPortal">Submit Claim</a></li>
							<li><a href="MyAccount">View Claim</a></li>
						</ul>
					</li>
					<li><a href="MyAccount">My Account</a></li>
				</c:if>
				</sec:authorize>
				<li><a href="locatedoctor">Find a Doctor</a></li>
			</ul>
		</div>
		<!-- /navContainer -->
	</div>
	<!-- /secondHeaderContainer -->
	<div id="thirdHeaderContainer">
		<div class="lowerheaderContainer">
			<c:if test="${pageContext.request.userPrincipal.name != null}">
				<ol>
					<li><a href="<c:url value="/MyAccount" />">${pageContext.request.userPrincipal.name}</a></li>
					<li>|</li> 
	                <li><a href="<c:url value="/Logout" />" > Logout</a></li>
                 </ol> 
			</c:if>
			<c:if test="${pageContext.request.userPrincipal.name == null}">
				<ol>
					<li><a href="Login">Log-In</a></li>
					<li>|</li>
					<li><a href="register">Register</a></li>
				</ol>
			</c:if>
		</div>
		<!-- /lowerHeader-->
	</div>
	<div id="bodyWrapper3">
		<div class="imgHeader">
			<h2>Contact Us</h2>
			<a href="ContactUs">Go Back</a>
		</div>
		<div class="ContactContainer">
			<div>
				<h3>Request Information about Acme Insurance Plans</h3>
			</div>
			<div>
				<h5>Health insurance information for me and family</h5>
			</div>
				<p>
					We offer a large variety of plan choices for individuals and families looking for affordable, dependable health care coverage.
				</p>
				<a class="openForm" href="#">Request for health insurance information for individuals</a>
			<div>
				<h5>Health insurance information for groups</h5>
			</div>
				<p>
					We offer coverage for groups from two to thousands of employees, including innovative plans with accounts and health support to help keep employees healthy and costs down.
				</p>
				<a class="openForm" href="#">Request for health insurance information for individuals</a>
			<br>
			<div class="dialog">
				<div id="RequestForm">
					<form:form method="POST" commandName = "contactUsForm">
						<table>
							<tr>
								<td><label>First Name</label></td>
								<td><form:input type="text" name="firstName" path="fName"/></td>
							</tr>
							<tr>
								<td><label>Last Name</label></td>
								<td><form:input type="text" name="LastName" path="lName"/></td>
							</tr>
							<tr>
								<td><label>Street Address</label></td>
								<td><form:input type="text" name="Address" path="address1"/></td>
							</tr>
							<tr>
								<td></td>
								<td><form:input type="text" name="Address" path="address2"/></td>
							</tr>
							<tr>
								<td><label>City</label></td>
								<td><form:input type="text" name="City" path="city"/></td>
							</tr>
							<tr>
								<td><label>State</label></td>
								<td>
									<form:select name="state" path="state">
										<form:option value="AL">Alabama</form:option>
										<form:option value="AK">Alaska</form:option>
										<form:option value="AZ">Arizona</form:option>
										<form:option value="AR">Arkansas</form:option>
										<form:option value="CA">California</form:option>
										<form:option value="CO">Colorado</form:option>
										<form:option value="CT">Connecticut</form:option>
										<form:option value="DE">Delaware</form:option>
										<form:option value="DC">District of Columbia</form:option>
										<form:option value="FL">Florida</form:option>
										<form:option value="GA">Georgia</form:option>
										<form:option value="HI">Hawaii</form:option>
										<form:option value="ID">Idaho</form:option>
										<form:option value="IL">Illinois</form:option>
										<form:option value="IN">Indiana</form:option>
										<form:option value="IA">Iowa</form:option>
										<form:option value="KS">Kansas</form:option>
										<form:option value="KY">Kentucky</form:option>
										<form:option value="LA">Louisiana</form:option>
										<form:option value="ME">Maine</form:option>
										<form:option value="MD">Maryland</form:option>
										<form:option value="MA">Massachusetts</form:option>
										<form:option value="MI">Michigan</form:option>
										<form:option value="MN">Minnesota</form:option>
										<form:option value="MS">Mississippi</form:option>
										<form:option value="MO">Missouri</form:option>
										<form:option value="MT">Montana</form:option>
										<form:option value="NE">Nebraska</form:option>
										<form:option value="NV">Nevada</form:option>
										<form:option value="NH">New Hampshire</form:option>
										<form:option value="NJ">New Jersey</form:option>
										<form:option value="NM">New Mexico</form:option>
										<form:option value="NY">New York</form:option>
										<form:option value="NC">North Carolina</form:option>
										<form:option value="ND">North Dakota</form:option>
										<form:option value="OH">Ohio</form:option>
										<form:option value="OK">Oklahoma</form:option>
										<form:option value="OR">Oregon</form:option>
										<form:option value="PA">Pennsylvania</form:option>
										<form:option value="RI">Rhode Island</form:option>
										<form:option value="SC">South Carolina</form:option>
										<form:option value="SD">South Dakota</form:option>
										<form:option value="TN">Tennessee</form:option>
										<form:option value="TX">Texas</form:option>
										<form:option value="UT">Utah</form:option>
										<form:option value="VT">Vermont</form:option>
										<form:option value="VA">Virginia</form:option>
										<form:option value="WA">Washington</form:option>
										<form:option value="WV">West Virginia</form:option>
										<form:option value="WI">Wisconsin</form:option>
										<form:option value="WY">Wyoming</form:option>
									</form:select>
								</td>
							</tr>
							<tr>
								<td><label>Zip Code</label></td>
								<td><form:input type="text" name="ZipCode" path="zip"/></td>
							</tr>
							<tr>
								<td><label>E-mail</label></td>
								<td><form:input type="text" name="Email" path="email"/></td>
							</tr>
							<tr>
								<td><label>Phone Number</label></td>
								<td><form:input type="text" name="Phone" path="phoneNum"/></td>
							</tr>
							<tr>
								<td><label>Best time to call</label></td>
								<td><form:input type="text" name="BestCall" path="timeToCall"/></td>
							</tr>
							<tr>
								<td><label>Age</label></td>
								<td><form:input type="text" name="Age" path="age"/></td>
							</tr>
							<tr>
								<td><input type="Submit" value="Submit"/></td>
								<td><input type="Submit" value="Reset"/></td>
							</tr>
						</table>
					</form:form>
				</div>
			</div>
		</div>
	</div>
	<div id="footer">
		<div class="footerwrap">
			<div class="foota">
				<br>
				<p>Connect With Us</p>
				<div id="footapad">
					<a href="#"><img src="resources/mytheme/images/fb.png" id="facebook" alt="logo" width="67" height="73" /></a> 
					<a href="#"><img src="resources/mytheme/images/twit.png" id="twitter" alt="logo" width="65" height="73" /></a>
					<a href="#"><img src="resources/mytheme/images/pin.png" id="pintrest" alt="logo" width="67" height="73" /></a>
				</div>
			</div>
			<div class="footb">
				<br>
				<p>Toll Free: 1-800-382-3827</p>
				<ol>
					<li>Acme Corporate</li>
					<li>143 23rd Ave South</li>
					<li>Fargo, North Dakota 58121</li>
				</ol>
			</div>
			<div class="footc">
				<br>
				<p>Need Help?</p>
				<ol>
					<li><a href="ContactUs">Contact Us</a></li>
					<li><a href="LocateDoctor">Get Directions</a></li>
					<li><a href="FAQ">FAQ's</a></li>
				</ol>

			</div>
		</div>
		<!-- FooterWrap -->
	</div>
	<!-- Footer -->
</body>
</html>